From the Research
The ICD-10 code for a preoperative examination is Z01.818, which is used for encounters specifically for pre-procedural examinations. This code should be used when a patient is seen for the purpose of clearance or evaluation before a surgical procedure. For Medicare patients, you may need to add a secondary diagnosis code that indicates the reason for the surgery to establish medical necessity. If the preoperative exam reveals any abnormal findings or specific conditions that require management, those should be coded separately as additional diagnoses. When documenting a preoperative exam, be sure to include the type of surgery planned, any risk factors identified, and your assessment of the patient's fitness for the procedure. This helps support the medical necessity of the preoperative evaluation and ensures proper reimbursement. The preoperative examination code is important because it distinguishes this visit from routine check-ups and allows for appropriate tracking of pre-surgical care.
Key Points to Consider
- The preoperative examination is a critical component of surgical care, as it helps identify potential risks and optimize the patient's condition before surgery 1.
- A comprehensive history and physical examination are essential components of the preoperative evaluation, and should be used to assess the patient's risk for perioperative complications 1.
- The use of ICD-10 codes, such as Z01.818, can help ensure accurate tracking and reimbursement for preoperative care 2.
- It is essential to use the most up-to-date and relevant ICD-10 codes, as reimbursement policies and coding guidelines may change over time 2.
Best Practices for Preoperative Evaluation
- Use a standardized approach to preoperative evaluation, including a comprehensive history and physical examination 3.
- Consider the patient's medical history, current medications, and potential risks for perioperative complications when evaluating their fitness for surgery 1.
- Use ICD-10 codes, such as Z01.818, to ensure accurate tracking and reimbursement for preoperative care 2.